Ulcerative ColitisMini Case Study

Krista BlackwellSodexo Mid-Atlantic Dietetic Internship

January 6, 2014

Overview

I. Ulcerative Colitis

II. MNT in IBD

III. Case StudyI. History and PhysicalII. Medication and LabsIII. AssessmentIV. DiagnosesV. Goals and InterventionVI. Monitoring and EvaluationVII. Education

IV. Article Review

V. Resources

Ulcerative Colitis

• A form of IBD that effects the colon and rectum

• Causes: Genetic, environment, and “irritant”

• Inflammatory and abnormal immune response

• Dx made with sigmoidoscopy

Side Effects• Diarrhea

• Fever

• Weight loss

• Anemia

• Food intolerances

• Malnutrition

• GI and/or rectal bleed

• Growth failure

Protein lossesElectrolyte

disturbancesDehydrationAnorexiaMalabsorptionAltered GI transitIncreased secretions

Healthy Colon vs. Ulcerative Colitis

MNT in IBD

• Goals: Reduce inflammation, alleviate symptoms, correct dehydration and nutritional deficiencies

• Individualized treatment

• Acute phase/ flare up: Low-fiber

• Remission: High protein (1.0-1.5 g/kg), nutrient-dense diet, 2 quarts of water daily

MNT in IBD

• Avoid: Diarrhea-causing foods, extreme temperatures, carbonated beverages, alcohol, caffeine, spicy foods, lactose

• Small frequent meals, eat slowly and chew well

• MVI with minerals: Thiamine, Vit E, iron, zinc, Ca, K, folic acid

Case Study: History and Physical

• CP is a 26 year old female

• PMHx: Dx with ulcerative colitis in 2011

• CP reported having multiple episodes of bloody diarrhea

• Distended abdomen and abdominal cramping

• NKA

Chief Complaint

• Nov. 2nd: CP presented with bloody bowel movements and fatigue, was put under observation and given Solu-Medrol and prednisone and d/c Nov. 3

• Nov. 6th: CP vomited her first dose of prednisone

• Nov. 9th: Early this morning, CP had one bloody BM an hour and presented to the ED and was admitted to SGAH for further evaluation and monitoring

Medical Diagnoses

• Ulcerative Colitis (Dx in 2011)

• Rectal bleeding

• Hemorrhage of the anus and rectum

• Hypokalemia

• Anemia

Social History

• CP is a 26 year-old Caucasian female

• Lives at home in Rockville, MD with her parents

• Manager at GAP• Works long hours• Limited access to food

Home Medications

Hospital Medications

Anthropometric Data

• Ht: 157cm (62”)

• Wt 11/9/13: 46.5 kg (102.3lb)

• Wt 11/3/13: 53.6 kg (118lb)

• UBW: 50kg (110lb)

• IBW: 50 kg (110lb)

• %IBW: 93%

• % wt change: 5% wt loss over 1 week

• BMI: 18.86

Laboratory Data

Nutrition Assessment

• Diet Order: Clear Liquid

• Intake: Fair

• Risk Level: Moderate

• Reason for visit: Diet Education

• Summary of visit• 8lb wt loss since last hospital admission on 11/3• Pt’s nausea subsided, able to consume clear liquid diet

and the doctor will be advancing her to full liquids• Tries to drink adequate fluids, usually about 3-4 bottles

of water a day• No BM since hospital admission• Provided pt with diet education for ulcerative colitis/

inflammatory bowel disease

Nutrition Prescription

• Estimated Energy Needs: 1388-1500kcal • (MSJ 1.2-1.3)

• Estimated Protein Needs: 38-47g (0.8-1.0 g/kg)

• Estimated Fluid Needs: 1500 mL (1mL/kcal)

• Micronutrient Needs: MVI with minerals

Nutrition Diagnoses

• Nutrition Diagnoses I:

Involuntary weight loss R/T ulcerative colitis AEB 5% wt loss over 1 week

• Diagnoses II:

Food and nutrition-related knowledge deficit R/T lack of prior exposure to nutrition-related information AEB no formal prior education while experiencing acute colitis symptoms

Goals

• Pt consume adequate energy intake: At least 75% of meals within the next 3-4 days.

• Pt maintain current weight and prevent further weight loss

• Patient to demonstrate knowledge of diet guidelines through menu selections prior to discharge

Interventions

Nutrition Education: Provided pt with information about a low fiber diet for the next few weeks and how to slowly reincorporate fiber into the diet

Food and Nutrition Delivery/ Meals and Snacks: As tolerated and as medically feasible, suggest advancing to a low fiber diet

MVI with minerals

Monitoring and Evaluation

• Monitor po intake

• Monitor pt’s wt trends

• RD to monitor understanding of information presented

Discharge Summary

• Discharged Nov. 13

• Diagnoses:• Ulcerative Colitis flare• Rectal bleeding secondary to ulcerative colitis

flare: Diarrhea and rectal bleed resolved• Anemia, which is stable• Acute dehydration• Hypokalemia, which is resolved

• Discharge medications: Prednisone and protonix

• Pt to follow up with GI doctor in 2 days

Nutrition Care in Adult IBD

• Nutrition Assessment• Identifying deficiencies and malnourished pts• Goals

• Diet in IBD

• Common Deficiencies: Fe, Zinc, Mg, Vit B12, Folate, Vit D and Ca

• Omega 3s

• Enteral and Parenteral Nutrition

Nutrition Issues in Gastroenterology, June 2012Authors: Amar S. Naik and Nanda Venu

Remission Induction and Maintenance Effect of Probiotics on Ulcerative Colitis: A meta-analysis

• Aim: To evaluate the induction of remission and maintenance effects of Probiotics for UC

• 13 randomized controlled trials from MEDLINE, EMBASE, Coch rane Controlled Trials Register

• Evaluates probiotic’s curative effects for treating UC based on existing random control trials

World Journal of Gastroenterology, April 2010Authors: Li-Xuan Sang, Bing Chang, Wen-Liang Zhang, Xiao-Mei Wu, Xiao-Hang Li, Min Jiang

Remission Induction and Maintenance Effect of

Probiotics on Ulcerative Colitis: A meta-analysis

• Results: Further research is needed including variations of bacterial species, applied dosage, treatment timing, and course of treatment

• Results were not consistent

Resources

• Mahan, K.., Escott-Stump, S, Raymond, J. Krause’s Food and the Nutrition Care Process. 3rd ed. Elsevier Saunders. 2012

• Width, Mary; Reinhard, Tonia. The Clinical Dietitian’s Essential Pocket Guide. Lippincott Williams & Wilkins. 2009.

• Naik, Amar S., Venu, Nanda. “Nutrition Care in Adult Inflammatory Bowel Disease.” Nutrition Issues in Gastroenterology, series #106. June 2012.

• Sang, Li-Xuan., Chang, Bing., Zhang, Wen-Liang., Wu, Xiao-Mei., Li, Xiao-Hang., Jiang, Min. “Remission induction and maintenance effect of probiotics on ulcerative colitis: A meta-analysis”. World Journal of Gastroenterology. April 2010.

Thank you!